JOB DESCRIPTION

Develops individualized treatment plans for patients, in collaboration with the patient, their family and the health care team. Coordinates and leads care conferences on patients per regulatory timeframes or more frequently as deemed necessary. Perform quarterly assessments for Westmoreland residents and completes appropriate minimum data set section within regulatory time frames. Documents unusual occurrences and patient relations issues, makes appropriate referrals to risk management, infection control and quality departments. Assesses patient and family needs for appropriate discharge services. Coordinates transfer to appropriate level of care such as outpatient rehabilitation and home health care. Documents discharge planning on the interdisciplinary plan of care, in progress notes and education record. Maintains current knowledge of resources available in the community to support a continuum of effective services for the patient. Delivers notice of Medicare non coverage and discharge appeal rights within the appropriate time frame. Performs medical record review to assess for appropriateness of admissions and continued hospital stay. Responds to requests by patient financial services for appeal assistance. Identifies appropriate cases requiring social work services. Collaborates with physicians and other healthcare personnel in patient evaluation and treatment to further their understanding of significant social and emotional factors underlying patient's health problems. Helps patient and family through individual or group conferences to understand, accept and follow medical recommendations. Provides appropriate services and referrals to restore patient to optimum social and health adjustment within patient's capacity. Utilizes current community resources to assist patient to resume life in community or to learn to live within limits of disability. Prepares patient histories, service plans and reports, provides consistent, accurate documentation of social work activities. Provides counseling to patients and families to assist them in coping with illness, hospitalization and treat, dying process, and financial management. Reports abuse, neglect, domestic violence and other required cases to appropriate authorities. Assists with transfer of patients to appropriate treatment facilities including substance abuse and psychiatric facilities when applicable. Initiates discussions with families regarding organ and tissue donation when applicable, facilitates referrals to appropriate agencies when applicable. Serves as a liaison to the ethics committee and actively assists patients and families with decision making involving complex ethical questions. Serves as a liaison to the palliative care team committee and actively assists patients and families with decision making and goals of care. Assists with social services referrals and resources for Adult Day Care participants as applicable. Performs crisis intervention with patient and family situations when applicable. Develops programs and educates patients and families on advance directives. Provides patient, staff and community education on topics related to health and psychosocial issues. EOE including Disabled and Veterans.
Required: Masters degree in social work. Licensed clinical social worker in the state of Illinois (LSCW). 5 to 7 years work experience in hospital setting or related setting. Critical thinking skills, decisive judgment and the ability to work with minimal supervision. Must be able to work in a stressful environment and take appropriate action.